Egg donor application

Egg Donor Application

If this is a cell phone number do you want to receive notifications via text messages *

YesNo

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth *

Spouse/Partners Name *

First

Last

Have you been a previous donor *

YesNo

How Would You Rate Your Physical Health *

ExcellentGoodAveragePoor

Height *

Weight *

Do you take any medications *

YesNo

If Yes, what medications *

Are there any significant genetic illnesses in your family *

YesNoUnknown

If Yes, please explain *

Have you or anyone in your family ever been diagnosed or treated for any serious emotional disorders *

YesNoUnknown

If Yes, please explain *

Do You Smoke *

YesNo

Do You Use Drugs *

YesNo

Do you have any criminal arrests *

YesNo

Are you available to travel if needed *

Yes, anywhereYes, but only within my state of residenceNo

How did you hear about A Family Tree Surrogacy, LLC *

GoogleBingFrom a Friend/FamilyFacebookTwitterOther social mediaFertility ClinicOther

By selecting "Agree", you are stating that you will and you have answered all questions to the best of your ability, without purposeful omission or deception. You understand being an egg donor is a serious responsibility and a process that requires maturity, excellent communication, honesty and a willingness to help others *

Agree

By selecting “Agree”, you understand the following: Some of the questions in this application are very personal. No answers will be shared with anyone outside of A Family Tree Surrogacy, LLC without your permission. Certain questions and answers are not shared with recipients and are only used for our internal purposes. *

Agree

By selecting "Agree", you are stating that you understand the treatment involves a evaluations, medical testing, a legal contract drafted by an attorney, and frequent visits to a fertility center. You may need to administer injections to yourself daily, for a period of weeks. You will also undergo blood draws and vaginal ultrasounds at the fertility clinic. *